The Dental Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider. During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In addition, they did not have effective systems to ensure dental records were stored securely. These concerns resulted in a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

We found staff to be open to discussion and feedback. The practice staff demonstrated a transparent and open culture in relation to people’s safety. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had effective processes to support and develop staff. Staff told us how they collected and responded to feedback from patients.

The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. Improvements were required to ensure policies were followed and kept up to date. For example, the staff recruitment policy was in line with schedule 3 requirements however, the practice was not following it as they were not maintaining records in line with the policy. Also, staff training was not collated and monitored in line with their policy. Processes for identifying and managing risks, issues and performance required improvements. There was no sharps risk assessment. There were risks relating to fire that the practice needed to rectify. A fire risk assessment had been completed and areas for improvement were identified. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service. The practice had installed closed-circuit television to improve security for patients and staff. Siting of CCTV cameras was appropriate. Relevant signage was not displayed. We discussed this with the practice, and they said they would review their processes. The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic`care records. Not all records were stored securely to comply with General Data Protection Regulations. Improvements were required to the practice systems and processes for learning, quality assurance and continuous improvement. Infection control audits were completed every six months in line with guidance however, we found that the audits were not always identifying issues. For example, the audits had not identified issues such as disjoined surfaces, sinks with overflows and local anaesthetics not being in blister packs.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.